A Scheme of Early Supported Discharge for Elderly Trauma Patients: The Views of Patients, Carers and Community Staff

This collaborative scheme of Early Supported Discharge, involving hospital and community staff and based in the Orthopaedic Directorate, Royal Infirmary of Edinburgh NHS Trust, has improved early rehabilitation, discharge planning and follow-up for trauma patients aged over 70 and admitted from home and has produced substantial reductions in length of hospital stay. Central to the scheme is a dedicated occupational therapist who coordinates discharge arrangements for eligible patients. An evaluation of the experiences of patients, carers, general practitioners and other community staff indicated that shorter stays in hospital have been achieved without undue problems for patients during the immediate post-discharge period.

Early supported discharge for elderly trauma patients: a report on a preliminary study

To cope with increasing numbers of elderly patients in acute orthopaedic units, various schemes have been introduced to expedite early rehabilitation and discharge. This paper reports a study undertaken in a large Scottish teaching hospital in order to assess the potential and requirements for a local scheme of early supported discharge for elderly trauma patients. Over a four-month period, data were collected from and about elderly patients (70+) admitted from home to the orthopaedic unit (overall sample of 282, detailed subsample of 100). Existing arrangements were shown to allow the apparently satisfactory direct discharge home of a substantial proportion (45%) of these patients in spite of their age (mean 80.2 years) and the fact that previous frailty was common and many (59%) lived alone. Findings of the study suggested that the number of discharges directly home could be increased with improved early rehabilitation, better pain control, systematic discharge planning, occupational therapy input and stronger links between the orthopaedic ward and the community services. Early clinical predictions of individual potential for direct discharge were unreliable. In a Scheme of Early Supported Discharge now in operation following the preliminary study, all patients admitted directly from home are considered.

How professionals define medicines management: a preliminary qualitative investigation

Focal points

The assessment of pain in older people

Pain is under-recognised and under-treated in older people. It is a subjective, personal experience, only known to the person who suffers. The assessment of pain is particularly challenging in the presence of severe cognitive impairment, communication difficulties or language and cultural barriers. These guidelines set out the key components of assessing pain in older people, together with a variety of practical scales that may be used with different groups, including those with varying levels of cognitive or communication impairment. The purpose is to provide professionals with a set of practical skills to assess pain as the first step towards its effective management. The guidance has implications for all healthcare and social care staff and can be applied in all settings, including the older person's own home, in care homes, and in hospital.

Patients’ perceptions of the impact of treatments and products on their experience of leg ulcer pain

OBJECTIVE

Very little research has explored patients' experience of pain with different cleansing agents and dressings. We therefore undertook a longitudinal study of their impact on leg ulcer pain.

METHOD

Patients with leg ulcers referred to community nurses were eligible to participate. They were followed up for six months, completing questionnaires about the impact on pain of each wound treatment used. A treatment episode was defined as the use of a wound cleansing agent, primary dressing and bandages. When one aspect of treatment changed, a new treatment episode began.

RESULTS

There were 210 treatment episodes for 96 leg ulcer patients. In 206 episodes cleansing agents were used. Cleansing caused pain in 22% of episodes and relieved pain in 27%. Of the five most commonly used dressing types, low-adherent dressings were the least likely to cause pain. Only 56% of patients were able to tolerate full compression bandaging and pain was the most common reason for non-compliance.

CONCLUSION

A substantial proportion of patients felt that leg ulcer treatments caused pain. A greater emphasis on the impact of treatment on pain and healing is warranted both clinically and in research.

Barriers to research implementation by community nurses

This article presents the community findings from a study of nurses in community and acute settings using Funk et al's Barriers to Research Utilization Scale (Barriers) (Funk et al, 1991a), which aimed to identify the main barriers to implementing research in practice. The Barriers questionnaire was sent to all nurses working in three community trusts in Yorkshire (n=2327), and practice nurses in one Yorkshire health authority (n=190). A 51.5% response rate gave a sample of 1297 nurses. The top two barriers were reported to be lack of time and resources. There were significant differences between sub-samples, e.g. older women perceived more barriers than younger colleagues, and practice nurses had particular problems with the cooperation of GPs. Factor analysis generated four new factors different from those found by Funk et al (1991a) (shown in brackets): benefits (nurse characteristics); quality (research characteristics); accessibility (presentation of the research characteristics) and resources (setting characteristics). Recommendations include developing nurses' critical appraisal skills so that, given more time and adequate resources, research findings might be judiciously implemented in practice.

Evidence for nursing practice: a clarification of the issues

There has been considerable confusion and unease within the nursing profession about the emphatic push for all healthcare to be 'evidence-based'. In particular, there has been anxiety that the emphasis on evidence ignores practitioners' skills and individual patient preferences. This paper attempts to clarify the main issues surrounding evidence-based nursing. These include its epidemiological origins and purpose, the meaning and limits of 'evidence', the need for individual skills and expertise in the use of evidence, and the strengths and weaknesses of different kinds of evidence. It aims to debunk the misconception that randomized controlled trials are synonymous with evidence, and to increase critical awareness of the nature of evidence in nursing.

Implementation of research findings to reduce postoperative pain at night

This study was designed to introduce and evaluate a research-based intervention to improve night-time pain management. It involved the provision of patient information and the introduction of structured night-time pain assessment. The implementation of the intervention was undertaken by local opinion leader. The study involved 417 patients from two matched orthopaedic wards in a before and after trial with comparison group. Outcomes of night-time pain control were elicited from ward documentation and patients by structured interviews on the second postoperative morning. These incorporated retrospective pain assessments, analgesic provision and nursing comfort measures provided the previous night. The intervention was associated with statistically significant reductions in both average and worst overnight pain scores. The frequency of night-time pain assessment by nursing staff increased significantly, although patients did not volunteer reports of pain more frequently and analgesics and other comfort measures were no more frequent. The intervention required an investment in educational support but no additional resources were needed for the successful reduction in pain scores.

Pressure sore management in the independent sector: 2

This is the second of two articles looking at pressure sore prevention and treatment in the independent sector of a large northern city. Part one presented background information, details of data collection and analysis, baseline data on current practice and initial conclusions which included an assessment of the extent of evidence-based practice, equipment use, educational needs, patient and informal carer involvement and quality of care maintenance. Part two considers these findings in greater depth. Both positive and negative aspects of pressure sore management in the independent sector are explored. Factors such as the number and types of pressure-relieving equipment used and the lack of independent evidence regarding product efficacy are considered. The survey highlights gaps in educational provision, and the lack of research evidence on certain aspects of care. The article concludes with a detailed series of recommendations with regard to practice, education and research.

Pressure sore management in the independent sector: 1

Little is known about pressure sore prevention and treatment in the independent sector. With a rapidly increasing number of care settings taking over responsibility for continuing care, particularly for elderly people, it is important that essential nursing care is provided at nationally agreed standards. This is the first of two articles which explore current practice in the independent sector of a large northern city. Background information on the study, details of data collection and analysis and baseline data on current practice are presented. This study investigates the extent of evidence-based practice, equipment use, educational needs, patient and informal carer involvement and maintenance of quality of care. Initial conclusions indicate that pressure sore management in the independent sector is evidence-based. However, in many areas of practice, personal observations and experience continue to take precedence over research evidence.

Collaborating on the integration of cancer nursing services

This article outlines the proposals contained in the Calman-Hine report (DoH 1995), and then presents the work of a nursing task group set up in response to its recommendations. The authors describe how different agencies collaborated in a network approach to improving the provision of cancer services.

Audit or research--what is the difference?

Audit and research are activities which have some characteristics in common and others which are rather different. This paper presents working definitions of each process and then examines their attributes and interrelationships in some detail. Areas covered include their purposes, what types of process they are, their theoretical bases, the methods used in each, sampling, the use of findings, confidentiality and the time frame of each. If nurses are to use or undertake research and/or audit appropriately in their practice, it is important that the similarities and differences between the two are clear.

Patient focused menu planning: an ENB project in a hospice

This paper discusses how a small study of the meals provided for patients in a hospice was undertaken as part of the ENB 931 Care of the Dying course, and used to change practice. The authors describe how the study provided not only useful information about the types and aspects of food both enjoyed and disliked in this setting, but also stimulated interest among nursing and kitchen staff, resulting in a programme of changes in menu planning. It is argued that while the project was undertaken as a piece of research, it actually had more in common with audit, and that audit might be a more useful activity to incorporate into ENB courses.

Pain and elderly patients: a survey of nurses' knowledge and experiences

Two hundred and eight qualified hospital nurses each completed a short questionnaire about pain and pain control in patients aged 70 years and over. Their awareness of the prevalence of chronic pain and its negative consequences was good, as was their knowledge of methods of assessing pain. Many, however, harboured misconceptions about the pharmacological treatment of pain and exaggerated the risk of opioid-induced respiratory depression. A wide range of complementary methods of pain control had been used by many of the nurses, and considerable interest was expressed in developing these skills further. Nurses from acute surgical areas tended to have a better knowledge of issues related to pain in elderly people than those from care of the elderly wards.

Pain in elderly patients: a neglected phenomenon?

The assessment and control of pain in elderly patients present unique problems. Old people are likely to experience more pain, both chronic and acute, than their younger counterparts. Demographic changes mean that larger numbers of older patients will require effective and efficient control of pain in order to optimize their quality of life. Relatively little research has focused on this potentially huge problem. This paper discusses issues specific to pain in elderly people, and suggests that wide ranging and careful assessments are needed. Benefits can be achieved not only from the appropriate use of analgesic drugs, but also physical and psychological therapies.

Older patients' experiences of discharge from hospital

The second paper in a series describes the work of the Nursing Research Unit at the University of Edinburgh studying discharge planning for older patients going home from acute hospital care is described. Data were collected on the views and experiences of 326 patients aged 75 years and over and 117 of their carers. Ward sisters also completed questionnaires about ward structures and processes relating to discharge planning. Problems typical of those reported in previous similar studies were found.

Utilization of nursing research: culture, interest and support

This paper acknowledges that the successful utilization of nursing research in practice is a highly complex task. Basic requisites include a positive research culture associated with the essential interest and support needed to promote change. Within this framework factors concerned with the research culture within nursing and the NHS are considered, as well as the research-practice gap, the role of researchers, educational issues and the need for both local and national support. Comparisons are made with the more positive research culture in the USA, and some American research utilization models are mentioned. It is suggested that research is not highly regarded in the UK and that the required level of interest and support depend on nursing research becoming an expected, valued and rewarded activity. Some general suggestions for actions which should promote research utilization are made.

Orthopaedics. Malnutrition: the key to pressure sores?

Elderly orthopaedic patients comprise a rapidly expanding population and suffer a high incidence of pressure sores compared to their younger counterparts. Malnutrition is one of the five most commonly cited risk factors for the development of pressure sores. This article briefly discusses the causes and effects of poor nutrition in elderly patients, and focuses on the importance of assessment of nutritional status in this group. Suggestions for the detection of malnutrition in elderly orthopaedic patients are made, with a view to reducing the incidence of pressure sores.

The complexities of using a structure, process and outcome framework: the case of an evaluation of discharge planning for elderly patients

Effective planning for discharge from hospital of elderly patients is becoming increasingly important as the elderly population rises. Donabedian's structure-process-outcome framework was used for an evaluation of discharge planning at a large teaching hospital. This paper discusses first the difficulties of defining the boundaries between each of the three Donabedian categories, and then makes some suggestions as to what factors require inclusion when considering the structures, processes and outcomes of discharge planning for elderly patients.

Patients' night-time pain, analgesic provision and sleep after surgery

One hundred patients were interviewed about their experiences of pain and sleep following abdominal surgery. This information was supplemented by data on analgesic provision which were gathered from medication charts. Pain was the most commonly reported cause of night-time sleep disturbance and analgesics helped more patients to get back to sleep than any other intervention. About half of the patients felt that pain was worse at night than during the day. An examination of patterns of analgesic provision revealed that the number of doses given peaked at two points during the 24-hour cycle. The highest numbers of doses were given between 8 a.m. and 12 noon and 8 p.m. and 12 midnight. Fewer doses were given at night, between midnight and 4 a.m. Analgesic provision at night, therefore, did not appear to be explicitly related to need. The assessment and control of post-operative pain at night requires further attention in order to optimize pain control and promote sleep.

Knowledge, expectations and experiences of patients receiving chemotherapy for breast cancer

The experiences of a cohort of 60 women receiving chemotherapy in treatment of breast cancer were monitored in an in-depth prospective study. The purpose of the investigation was to identify ways in which nurses could improve the preparation and support of patients undergoing chemotherapy. It was found that patients' knowledge of chemotherapy was limited and that the side-effects they experienced, and their reactions to these, were rather different and more diverse than had been expected. The study illustrates the value of exploring patients' perceptions of their problems and needs for information and support.

Theatre gowns: a survey of the extent of user protection

This paper describes a survey of contamination by blood and other body fluids to theatre staff during general and orthopaedic surgery. Fourteen surgeons completed questionnaires following 243 operations, providing information describing the extent of contamination. Recommendations are made for more extensive precautions to be taken when operating on patients considered to be at high-risk of carrying human immunodeficiency virus (HIV). Further assessment of the reliability and comfort of impermeable gowns is required.

An exploratory analysis of nurses' provision of postoperative analgesic drugs

Adequate pain relief during the postoperative period has long been recognized as difficult to accomplish. The reasons for this are mentioned in a brief review of methods of pain control, and an overview of the detrimental effects of acute pain is given. This retrospective analysis of data from 36 patients set out to examine whether those whose night-time sleep was found to be disturbed by pain were subject to different patterns of analgesic provision from those whose sleep was not. Although no such differences emerged, it was found that analgesics were given approximately half as frequently during the night when compared with during the day. It was also noted that only 30-35% of the maximum doses of analgesics prescribed were actually given within the immediate postoperative period. The possible reasons for these findings are discussed.

Assessment of sleep in hospital patients: a review of methods

Since sleep and healing appear to be associated, achieving the optimum quality of sleep among hospital patients should be a priority for both clinical nurses and researchers. This paper discusses various methods of sleep assessment which may be used by those intending to conduct research in this field.

Factors affecting perioperative body temperature

Factors affecting body temperature in the perioperative period were investigated in two groups of surgical patients (cholecystectomy and repair of fractured femur). Core, toe skin and thigh skin temperatures were assessed pre and postoperatively for all subjects. A control group showed a significant fall in toe skin temperature only during exposure to theatre conditions, whereas all of the surgical patients underwent falls in core temperature. The fractured femur patients sustained significantly greater reductions in core temperature than the cholecystectomy patients. Age and ambient theatre temperature were found to be the most influential factors affecting this fall in core temperature. Body composition had less of an influence than these two variables, but it was found that the patients with the greatest body fat contents had the smallest reductions in core temperature. Seven of the 31 patients returned to the ward with core temperatures below 35 degrees C, and only one of these seven received assistance in rewarming. Four of the 31 patients developed significantly higher core temperatures than the remaining 27 during the immediate postoperative period, and these four subsequently developed respiratory tract infections. Standard monitoring of temperature on the wards during the immediate postoperative period failed to identify postoperative hypothermia or pyrexia in the majority of cases.